midway neurological rehab ctr 2018 0047175 · 2019. 8. 22. · 3 PAC Expenses (243) 20 3 4 RP Profit (96) 10 4 5 RP Profit (820) 15 5 6 RP Profit (3,131) 39 6 7 Miscellaneous Income

FOR BHF USE IMPORTANT NOTICELL1 THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION

THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY2018 PURPOSE AS OUTLINED IN 210 ILCS 45/3-208. DISCLOSURE

STATE OF ILLINOIS OF THIS INFORMATION IS MANDATORY. FAILURE TO PROVIDEDEPARTMENT OF HEALTHCARE AND FAMILY SERVICES ANY INFORMATION ON OR BEFORE THE DUE DATE WILLFINANCIAL AND STATISTICAL REPORT (COST REPORT) RESULT IN CESSATION OF PROGRAM PAYMENTS. THIS FORM

FOR LONG-TERM CARE FACILITIES HAS BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.(FISCAL YEAR 2018)

I. IDPH License ID Number: 0047175 II. CERTIFICATION BY AUTHORIZED FACILITY OFFICER

Facility Name: Midway Neurological & Rehabilitation Center I have examined the contents of the accompanying report to the

Address: 854 South Harlem Avenue Bridgeview 60455 State of Illinois, for the period from 1/1/18 to 12/31/18Number City Zip Code and certify to the best of my knowledge and belief that the said contents

are true, accurate and complete statements in accordance withCounty: Cook applicable instructions. Declaration of preparer (other than provider)

is based on all information of which preparer has any knowledge.Telephone Number: (708) 449-1900 Fax # (708) 449-1500

Intentional misrepresentation or falsification of any informationHFS ID Number: in this cost report may be punishable by fine and/or imprisonment.

Date of Initial License for Current Owners: 04/01/2005 (Signed)Officer or (Date)

Type of Ownership: Administrator (Type or Print Name) Paresh Vipani of Provider

VOLUNTARY,NON-PROFIT X PROPRIETARY GOVERNMENTAL (Title) CFOCharitable Corp. Individual StateTrust Partnership County (Signed)

IRS Exemption Code Corporation Other (Date)"Sub-S" Corp. Paid (Print Name Daniel S. Gaafar

X Limited Liability Co. Preparer and Title) PartnerTrustOther (Firm Name Bradley Associates

& Address) 201 S. Capitol Avenue, Suite 700, Indianapolis, IN 46225

(Telephone) (317) 237-5500 Fax #(317) 237-5503 MAIL TO: BUREAU OF HEALTH FINANCE

In the event there are further questions about this report, please contact: ILLINOIS DEPT OF HEALTHCARE AND FAMILY SERVICESName:Daniel S. Gaafar Telephone Number: (317) 237-5500 201 S. Grand Avenue East

Email Address: Springfield, IL 62763-0001 Phone # (217) 782-1630

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 2Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

III. STATISTICAL DATA D. How many bed reserve days during this year were paid by the Department?A. Licensure/certification level(s) of care; enter number of beds/bed days, 0 (Do not include bed reserve days in Section B.) (must agree with license). Date of change in licensed beds N/A

E. List all services provided by your facility for non-patients. 1 2 3 4 (E.g., day care, "meals on wheels", outpatient therapy)

None Beds at Licensed Beginning of Licensure Beds at End of Bed Days During F. Does the facility maintain a daily midnight census? Yes Report Period Level of Care Report Period Report Period

G. Do pages 3 & 4 include expenses for services or1 404 Skilled (SNF) 404 147,460 1 investments not directly related to patient care?2 Skilled Pediatric (SNF/PED) 2 YES NO X3 Intermediate (ICF) 34 Intermediate/DD 4 H. Does the BALANCE SHEET (page 17) reflect any non-care assets?5 Sheltered Care (SC) 5 YES NO X6 ICF/DD 16 or Less 6

I. On what date did you start providing long term care at this location?7 404 TOTALS 404 147,460 7 Date started 04/01/2005

J. Was the facility purchased or leased after January 1, 1978?B. Census-For the entire report period. YES X Date 04/01/2005 NO

1 2 3 4 5 Level of Care Patient Days by Level of Care and Primary Source of Payment K. Was the facility certified for Medicare during the reporting year?

Medicaid YES X NO If YES, enter numberRecipient Private Pay Other Total of beds certified 404 and days of care provided 3,292

8 SNF 122,265 363 7,258 129,886 8 9 SNF/PED 9 Medicare Intermediary National Government Services10 ICF 1011 ICF/DD 11 IV. ACCOUNTING BASIS12 SC 12 MODIFIED13 DD 16 OR LESS 13 ACCRUAL X CASH* CASH*

14 TOTALS 122,265 363 7,258 129,886 14 Is your fiscal year identical to your tax year? YES X NO

C. Percent Occupancy. (Column 5, line 14 divided by total licensed Tax Year: 12/31/18 Fiscal Year: 12/31/18 bed days on line 7, column 4.) 88.08% * All facilities other than governmental must report on the accrual basis.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 3Facility Name & ID Number Midway Neurological & Rehabilitation Cente # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18V. COST CENTER EXPENSES (throughout the report, please round to the nearest dollar)

Costs Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Operating Expenses Salary/Wage Supplies Other Total ification Total ments TotalA. General Services 1 2 3 4 5 6 7 8 9 10

1 Dietary 665,005 94,797 19,476 779,278 779,278 (4,243) 775,035 12 Food Purchase 753,557 753,557 753,557 2,842 756,399 23 Housekeeping 347,092 68,507 415,599 415,599 30 415,629 34 Laundry 72,893 33,907 106,800 106,800 106,800 45 Heat and Other Utilities 440,016 440,016 440,016 (14,093) 425,923 56 Maintenance 277,861 93,169 247,869 618,899 618,899 2,574 621,473 67 Other (specify):* 7

8 TOTAL General Services 1,362,851 1,043,937 707,361 3,114,149 3,114,149 (12,890) 3,101,259 8B. Health Care and Programs

9 Medical Director 35,675 35,675 35,675 35,675 910 Nursing and Medical Records 4,909,228 344,130 47,169 5,300,527 5,300,527 38,277 5,338,804 10

10a Therapy 1,034,327 1,034,327 1,034,327 1,034,327 10a11 Activities 462,690 112,528 575,218 575,218 575,218 1112 Social Services 493,398 5,440 498,838 498,838 498,838 1213 CNA Training 1314 Program Transportation 1415 Other (specify):* RX Consultant 38,331 38,331 38,331 (820) 37,511 15

16 TOTAL Health Care and Programs 5,865,316 456,658 1,160,942 7,482,916 7,482,916 37,457 7,520,373 16C. General Administration

17 Administrative 234,248 234,248 234,248 234,248 1718 Directors Fees 1819 Professional Services 1,037,103 1,037,103 1,037,103 (789,304) 247,799 1920 Dues, Fees, Subscriptions & Promotions 9,368 9,368 9,368 (56) 9,312 2021 Clerical & General Office Expenses 199,450 92,700 (25,436) 266,714 266,714 366,021 632,735 2122 Employee Benefits & Payroll Taxes 1,361,871 1,361,871 1,361,871 72,592 1,434,463 2223 Inservice Training & Education 2324 Travel and Seminar 21,066 21,066 21,066 5,960 27,026 2425 Other Admin. Staff Transportation 2526 Insurance-Prop.Liab.Malpractice 798,772 798,772 798,772 151,926 950,698 2627 Other (specify):* 27

28 TOTAL General Administration 433,698 92,700 3,202,744 3,729,142 3,729,142 (192,861) 3,536,281 28TOTAL Operating Expense

29 (sum of lines 8, 16 & 28) 7,661,865 1,593,295 5,071,047 14,326,207 14,326,207 (168,294) 14,157,913 29*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.NOTE: Include a separate schedule detailing the reclassifications made in column 5. Be sure to include a detailed explanation of each reclassification.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 4Facility Name & ID Number Midway Neurological & Rehabilitation Center #0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

#V. COST CENTER EXPENSES (continued)

Cost Per General Ledger Reclass- Reclassified Adjust- Adjusted FOR BHF USE ONLY Capital Expense Salary/Wage Supplies Other Total ification Total ments TotalD. Ownership 1 2 3 4 5 6 7 8 9 10

30 Depreciation 157,667 157,667 157,667 155,822 313,489 3031 Amortization of Pre-Op. & Org. 457,401 457,401 3132 Interest (2,709,126) (2,709,126) (2,709,126) 3,334,572 625,446 3233 Real Estate Taxes 1,071,662 1,071,662 1,071,662 1,071,662 3334 Rent-Facility & Grounds 1,186,353 1,186,353 1,186,353 (1,177,059) 9,294 3435 Rent-Equipment & Vehicles 3536 Other (specify):* Replacement Tax 31,275 31,275 31,275 31,275 36

37 TOTAL Ownership (262,169) (262,169) (262,169) 2,770,736 2,508,567 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 3839 Ancillary Service Centers 151,853 151,853 151,853 (3,131) 148,722 3940 Barber and Beauty Shops 4041 Coffee and Gift Shops 4142 Provider Participation Fee 987,493 987,493 987,493 987,493 4243 Other (specify):* Bad Debt Expense 325,396 325,396 325,396 (325,396) 43

44 TOTAL Special Cost Centers 151,853 1,312,889 1,464,742 1,464,742 (328,527) 1,136,215 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 7,661,865 1,745,148 6,121,767 15,528,780 15,528,780 2,273,915 17,802,695 45

*Attach a schedule if more than one type of cost is included on this line, or if the total exceeds $1000.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18VI. ADJUSTMENT DETAIL A. The expenses indicated below are non-allowable and should be adjusted out of Schedule V, pages 3 or 4 via column 7.

In column 2 below, reference the line on which the particular cost was included. (See instructions.) 1 2 3

Refer- BHF USE B. If there are expenses experienced by the facility which do not appear in the NON-ALLOWABLE EXPENSES Amount ence ONLY general ledger, they should be entered below.(See instructions.)

1 Day Care $ $ 1 1 22 Other Care for Outpatients 2 Amount Reference3 Governmental Sponsored Special Programs 3 31 Non-Paid Workers-Attach Schedule* $ 314 Non-Patient Meals 4 32 Donated Goods-Attach Schedule* 325 Telephone, TV & Radio in Resident Rooms 5 Amortization of Organization &6 Rented Facility Space 6 33 Pre-Operating Expense 337 Sale of Supplies to Non-Patients 7 Adjustments for Related Organization8 Laundry for Non-Patients 8 34 Costs (Schedule VII) 130,392 various 349 Non-Straightline Depreciation (39,050) 30 9 35 Other- Attach Schedule 35

10 Interest and Other Investment Income (145,100) 32 10 36 SUBTOTAL (B): (sum of lines 31-35) $ 130,392 3611 Discounts, Allowances, Rebates & Refunds 11 (sum of SUBTOTALS12 Non-Working Officer's or Owner's Salary 12 37 TOTAL ADJUSTMENTS (A) and (B) ) $ 2,273,915 3713 Sales Tax (11) 1 1314 Non-Care Related Interest 14 *These costs are only allowable if they are necessary to meet minimum15 Non-Care Related Owner's Transactions 15 licensing standards. Attach a schedule detailing the items included16 Personal Expenses (Including Transportation) 16 on these lines.17 Non-Care Related Fees 1718 Fines and Penalties 18 C. Are the following expenses included in Sections A to D of pages 319 Entertainment 19 and 4? If so, they should be reclassified into Section E. Please 20 Contributions (285) 21 20 reference the line on which they appear before reclassification.21 Owner or Key-Man Insurance 21 (See instructions.) 1 2 3 422 Special Legal Fees & Legal Retainers 22 Yes No Amount Reference23 Malpractice Insurance for Individuals 23 38 Medically Necessary Transport. X $ 3824 Bad Debt (325,396) 43 24 39 3925 Fund Raising, Advertising and Promotional (26,872) 21 25 40 Gift and Coffee Shops X 40

Income Taxes and Illinois Personal 41 Barber and Beauty Shops X 4126 Property Replacement Tax 26 42 Laboratory and Radiology X 4227 CNA Training for Non-Employees 27 43 Prescription Drugs X 4328 Yellow Page Advertising 28 44 4429 Other-Attach Schedule 2,680,237 various 29 45 Other-Attach Schedule 4530 SUBTOTAL (A): (Sum of lines 1-29) $ 2,143,523 $ 30 46 Other-Attach Schedule 46

47 TOTAL (C): (sum of lines 38-46) $ 47BHF USE ONLY

48 49 50 51 52

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 5AMidway Neurological & Rehabilitation Center

ID# 0047175Report Period Beginning: 1/1/18

Ending: 12/31/18Sch. V Line

NON-ALLOWABLE EXPENSES Amount Reference1 Miscellaneous Income $ (213) 21 12 Vending Income (4,232) 1 23 PAC Expenses (243) 20 34 RP Profit (96) 10 45 RP Profit (820) 15 56 RP Profit (3,131) 39 67 Miscellaneous Income (18,788) 5 78 Miscellaneous Income (1,366) 10 89 Interest Expense 2,709,126 32 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 3435 3536 3637 3738 3839 3940 4041 4142 4243 4344 4445 4546 4647 4748 4849 Total 2,680,237 49

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary AFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Operating Expenses PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSA. General Services 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

1 Dietary (4,243) 0 0 0 0 0 0 0 0 0 0 (4,243) 12 Food Purchase 0 2,842 0 0 0 0 0 0 0 0 0 2,842 23 Housekeeping 0 30 0 0 0 0 0 0 0 0 0 30 34 Laundry 0 0 0 0 0 0 0 0 0 0 0 0 45 Heat and Other Utilities (18,788) 4,695 0 0 0 0 0 0 0 0 0 (14,093) 56 Maintenance 0 2,574 0 0 0 0 0 0 0 0 0 2,574 67 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 78 TOTAL General Services (23,031) 10,141 0 0 0 0 0 0 0 0 0 (12,890) 8

B. Health Care and Programs9 Medical Director 0 0 0 0 0 0 0 0 0 0 0 0 9

10 Nursing and Medical Records (1,462) 39,739 0 0 0 0 0 0 0 0 0 38,277 10 10a Therapy 0 0 0 0 0 0 0 0 0 0 0 0 10a11 Activities 0 0 0 0 0 0 0 0 0 0 0 0 1112 Social Services 0 0 0 0 0 0 0 0 0 0 0 0 1213 CNA Training 0 0 0 0 0 0 0 0 0 0 0 0 1314 Program Transportation 0 0 0 0 0 0 0 0 0 0 0 0 1415 Other (specify):* (820) 0 0 0 0 0 0 0 0 0 0 (820) 15

16 TOTAL Health Care and Programs (2,282) 39,739 0 0 0 0 0 0 0 0 0 37,457 16C. General Administration

17 Administrative 0 0 0 0 0 0 0 0 0 0 0 0 1718 Directors Fees 0 0 0 0 0 0 0 0 0 0 0 0 1819 Professional Services 0 (793,204) 3,900 0 0 0 0 0 0 0 0 (789,304) 1920 Fees, Subscriptions & Promotions (243) 187 0 0 0 0 0 0 0 0 0 (56) 2021 Clerical & General Office Expenses (27,370) 393,391 0 0 0 0 0 0 0 0 0 366,021 2122 Employee Benefits & Payroll Taxes 0 72,592 0 0 0 0 0 0 0 0 0 72,592 2223 Inservice Training & Education 0 0 0 0 0 0 0 0 0 0 0 0 2324 Travel and Seminar 0 5,960 0 0 0 0 0 0 0 0 0 5,960 2425 Other Admin. Staff Transportation 0 0 0 0 0 0 0 0 0 0 0 0 2526 Insurance-Prop.Liab.Malpractice 0 2,505 149,421 0 0 0 0 0 0 0 0 151,926 2627 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 27

28 TOTAL General Administration (27,613) (318,569) 153,321 0 0 0 0 0 0 0 0 (192,861) 28TOTAL Operating Expense

29 (sum of lines 8,16 & 28) (52,926) (268,689) 153,321 0 0 0 0 0 0 0 0 (168,294) 29

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Summary BFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

SUMMARY OF PAGES 5, 5A, 6, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H AND 6I

SUMMARY Capital Expense PAGES PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE PAGE TOTALSD. Ownership 5 & 5A 6 6A 6B 6C 6D 6E 6F 6G 6H 6I (to Sch V, col.7)

30 Depreciation (39,050) 0 194,872 0 0 0 0 0 0 0 0 155,822 3031 Amortization of Pre-Op. & Org. 0 0 457,401 0 0 0 0 0 0 0 0 457,401 3132 Interest 2,564,026 0 770,546 0 0 0 0 0 0 0 0 3,334,572 3233 Real Estate Taxes 0 0 0 0 0 0 0 0 0 0 0 0 3334 Rent-Facility & Grounds 0 0 (1,177,059) 0 0 0 0 0 0 0 0 (1,177,059) 3435 Rent-Equipment & Vehicles 0 0 0 0 0 0 0 0 0 0 0 0 3536 Other (specify):* 0 0 0 0 0 0 0 0 0 0 0 0 36

37 TOTAL Ownership 2,524,976 0 245,760 0 0 0 0 0 0 0 0 2,770,736 37 Ancillary ExpenseE. Special Cost Centers

38 Medically Necessary Transportation 0 0 0 0 0 0 0 0 0 0 0 0 3839 Ancillary Service Centers (3,131) 0 0 0 0 0 0 0 0 0 0 (3,131) 3940 Barber and Beauty Shops 0 0 0 0 0 0 0 0 0 0 0 0 4041 Coffee and Gift Shops 0 0 0 0 0 0 0 0 0 0 0 0 4142 Provider Participation Fee 0 0 0 0 0 0 0 0 0 0 0 0 4243 Other (specify):* (325,396) 0 0 0 0 0 0 0 0 0 0 (325,396) 43

44 TOTAL Special Cost Centers (328,527) 0 0 0 0 0 0 0 0 0 0 (328,527) 44GRAND TOTAL COST

45 (sum of lines 29, 37 & 44) 2,143,523 (268,689) 399,081 0 0 0 0 0 0 0 0 2,273,915 45

HFS 3745 (N-4-99) IL478-2471


VII. RELATED PARTIES A. Enter below the names of ALL owners and related organizations (parties) as defined in the instructions. Use Page 6-Supplemental as necessary.

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of BusinessMichael Blisko 33.393% Ambassador Nursing and Rehab Center Chicago Infinity Healthcare Hillside Mgmt CoGELP 33.392% Belhaven Nursing and Rehab Chicago Midway Realty Company Property CoA&F Realty 23.965% West Suburban Nursing and Rehab Center Bloomingdale United RX Hillside Pharmacy CoJoseph Blisko 5% City View Multicare Center CiceroJoseph Meisels 4.25% Continental Nursing and Rehab Center Chicago

Forest View Rehab and Nursing Center ChicagoLakeview Nursing and Rehab Center Chicago

B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,management fees, purchase of supplies, and so forth. X YES NO

If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:

Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization

Ownership Organization Costs (7 minus 4)1 V 1 Dietary $ Infinity Healthcare Management of Illinois $ $ 12 V 2 Food Purchase Infinity Healthcare Management of Illinois 2,842 2,842 23 V 3 Housekeeping Infinity Healthcare Management of Illinois 30 30 34 V 5 Utilities Infinity Healthcare Management of Illinois 4,695 4,695 45 V 6 Maintenance Infinity Healthcare Management of Illinois 2,574 2,574 56 V 10 Nursing 47,482 Infinity Healthcare Management of Illinois 87,221 39,739 67 V 17 Administrative Infinity Healthcare Management of Illinois 78 V 19 Professional Fees 797,183 Infinity Healthcare Management of Illinois 3,979 (793,204) 89 V 20 Dues & Fees 88 Infinity Healthcare Management of Illinois 275 187 9

10 V 21 Office Expense 93,237 Infinity Healthcare Management of Illinois 486,628 393,391 1011 V 22 Employee Benefits 1,485 Infinity Healthcare Management of Illinois 74,077 72,592 1112 V 24 Travel Expenses 2,851 Infinity Healthcare Management of Illinois 8,811 5,960 1213 V 26 Insurance Infinity Healthcare Management of Illinois 2,505 2,505 1314 Total $ 942,326 $ 673,637 $ * (268,689) 14

* Total must agree with the amount recorded on line 34 of Schedule VI.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6AFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

VII. RELATED PARTIES (continued) B. Are any costs included in this report which are a result of transactions with related organizations? This includes rent,

management fees, purchase of supplies, and so forth. X YES NO

If yes, costs incurred as a result of transactions with related organizations must be fully itemized in accordance withthe instructions for determining costs as specified for this form.1 2 3 Cost Per General Ledger 4 5 Cost to Related Organization 6 7 8 Difference:

Percent Operating Cost Adjustments for Schedule V Line Item Amount Name of Related Organization of of Related Related Organization

Ownership Organization Costs (7 minus 4)15 V 30 Depreciation $ Infinity Healthcare Management of Illinois $ $ 1516 V 32 Interest Infinity Healthcare Management of Illinois 8,120 8,120 1617 V 34 Rent Infinity Healthcare Management of Illinois 9,294 9,294 1718 V 1819 V 1920 V 2021 V 19 Professional Fees Midway Neurological and Rehabilitation Realty 3,900 3,900 2122 V 26 Insurance Midway Neurological and Rehabilitation Realty 149,421 149,421 2223 V 30 Depreciation Midway Neurological and Rehabilitation Realty 194,872 194,872 2324 V 31 Amortization Midway Neurological and Rehabilitation Realty 457,401 457,401 2425 V 32 Interest Midway Neurological and Rehabilitation Realty 762,426 762,426 2526 V 34 Rent 1,186,353 Midway Neurological and Rehabilitation Realty (1,186,353) 2627 V 2728 V 2829 V 2930 V 3031 V 3132 V 3233 V 3334 V 3435 V 3536 V 3637 V 3738 V 38

39 Total $ 1,186,353 $ 1,585,434 $ * 399,081 39

* Total must agree with the amount recorded on line 34 of Schedule VI.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 6-SupplementalFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

VII. RELATED PARTIES A. (Continued) Enter below the names of ALL owners and related organizations (parties) as defined in the instructions

1 2 3 OWNERS RELATED NURSING HOMES OTHER RELATED BUSINESS ENTITIES

Name Ownership % Name City Name City Type of Business

1 Momence Meadows Nursing and Rehab Ctr Momence 12 Niles Nursing and Rehab Center Niles 23 Oak Lawn Respiratory and Rehab Center Oak Lawn 34 Parker Nursing and Rehab Center Streator 45 Parkshore Estates Nursing and Rehab Ctr Chicago 56 Southpoint Nursing and Rehab Center Chicago 67 Landmark of Des Plaines Rehab Center Des Plaines 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 30

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 7Facility Name & ID Number Midway Neurological & Rehabilitation Cente # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

VII. RELATED PARTIES (continued)C. Statement of Compensation and Other Payments to Owners, Relatives and Members of Board of Directors. NOTE: ALL owners ( even those with less than 5% ownership) and their relatives who receive any type of compensation from this home must be listed on this schedule.

1 2 3 4 5 6 7 8Average Hours Per Work

Compensation Week Devoted to this Compensation Included Schedule V.Received Facility and % of Total in Costs for this Line &

Ownership From Other Work Week Reporting Period** ColumnName Title Function Interest Nursing Homes* Hours Percent Description Amount Reference

1 $ 12 23 34 45 56 67 78 89 9

10 1011 1112 12

13 TOTAL $ 13

* If the owner(s) of this facility or any other related parties listed above have received compensation from other nursing homes, attach a schedule detailing the name(s)of the home(s) as well as the amount paid. THIS AMOUNT MUST AGREE TO THE AMOUNTS CLAIMED ON THE THE OTHER NURSING HOMES' COST REPORTS.

** This must include all forms of compensation paid by related entities and allocated to Schedule V of this report (i.e., management fees).FAILURE TO PROPERLY COMPLETE THIS SCHEDULE INDICATING ALL FORMS OF COMPENSATION RECEIVED FROM THIS HOME,ALL OTHER NURSING HOMES AND MANAGEMENT COMPANIES MAY RESULT IN THE DISALLOWANCE OF SUCH COMPENSATION

HFS 3745 (N-4-99) IL478-2471


VIII. ALLOCATION OF INDIRECT COSTS Name of Related Organization

A. Are there any costs included in this report which were derived from allocations of central office Street Address or parent organization costs? (See instructions.) YES NO X City / State / Zip Code

Phone Number ( ) B. Show the allocation of costs below. If necessary, please attach worksheets. Fax Number ( )

1 2 3 4 5 6 7 8 9Schedule V Unit of Allocation Number of Total Indirect Amount of Salary

Line (i.e.,Days, Direct Cost, Subunits Being Cost Being Cost Contained Facility AllocationReference Item Square Feet) Total Units Allocated Among Allocated in Column 6 Units (col.8/col.4)x col.6

1 $ $ $ 12 23 34 45 56 67 78 89 910 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 TOTALS $ $ $ 25

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 9Facility Name & ID Number Midway Neurological & Rehabilitation Cente # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18

IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE A. Interest: (Complete details must be provided for each loan - attach a separate schedule if necessary.)

1 2 3 4 5 6 7 8 9 10Reporting

Monthly Maturity Interest PeriodName of Lender Related** Purpose of Loan Payment Date of Amount of Note Date Rate Interest

YES NO Required Note Original Balance (4 Digits) ExpenseA. Directly Facility Related Long-Term

1 HUD Loan X Mortgage $97,534.00 5/25/15 $ 23,416,884 $ 22,236,371 7/1/49 3.4000 $ 770,546 12 23 34 45 5

Working Capital6 67 78 8

9 TOTAL Facility Related $97,534.00 $ 23,416,884 $ 22,236,371 $ 770,546 9B. Non-Facility Related*

10 1011 1112 1213 13

14 TOTAL Non-Facility Related $ $ $ 14

15 TOTALS (line 9+line14) $ 23,416,884 $ 22,236,371 $ 770,546 15

16) Please indicate the total amount of mortgage insurance expense and the location of this expense on Sch. V. $ 149,421 Line # 26

* Any interest expense reported in this section should be adjusted out on page 5, line 14 and, consequently, page 4, col. 7.(See instructions.)

** If there is ANY overlap in ownership between the facility and the lender, this must be indicated in column 2.(See instructions.)

HFS 3745 (N-4-99) IL478-2471


IX. INTEREST EXPENSE AND REAL ESTATE TAX EXPENSE (continued) B. Real Estate Taxes

Important, please see the next worksheet, "RE_Tax". The real estate tax 1. Real Estate Tax accrual used on 2017 report. statement and bill must accompany the cost report. $ 726,291 1

2. Real Estate Taxes paid during the year: (Indicate the tax year to which this payment applies. If payment covers more than one year, detail below.) $ 1,232,766 2

3. Under or (over) accrual (line 2 minus line 1). $ 506,475 3

4. Real Estate Tax accrual used for 2018 report. (Detail and explain your calculation of this accrual on the lines below.) $ 565,187 4

5. Direct costs of an appeal of tax assessments which has NOT been included in professional fees or other general operating costs on Schedule V, sections A, B or C. (Describe appeal cost below. Attach copies of invoices to support the cost and a copy of the appeal filed with the county.) $ 5

6. Subtract a refund of real estate taxes. You must offset the full amount of any direct appeal costs classified as a real estate tax cost plus one-half of any remaining refund. TOTAL REFUND $ For Tax Year. (Attach a copy of the real estate tax appeal board's decision.) $ 6

7. Real Estate Tax expense reported on Schedule V, line 33. This should be a combination of lines 3 thru 6. $ 1,071,662 7

Real Estate Tax History:

Real Estate Tax Bill for Calendar Year: 2013 799,313 8 FOR BHF USE ONLY2014 921,323 92015 953,008 10 13 FROM R. E. TAX STATEMENT FOR 2017 $ 132016 1,006,349 112017 1,232,766 12 14 PLUS APPEAL COST FROM LINE 5 $ 14

15 LESS REFUND FROM LINE 6 $ 15

16 AMOUNT TO USE FOR RATE CALCULATION $ 16

NOTES: 1. Please indicate a negative number by use of brackets( ). Deduct any overaccrual of taxes from prior year.

2. If facility is a non-profit which pays real estate taxes, you must attach a denial of an application for real estate tax exemption unless the building is rented from a for-profit entity. This denial must be no more than four years old at the time the cost report is filed.

HFS 3745 (N-4-99) IL478-2471

2017 LONG TERM CARE REAL ESTATE TAX STATEMENTFACILITY NAME Midway Neurological & Rehabilitation Center COUNTY Cook

FACILITY IDPH LICENSE NUMBER 0047175

CONTACT PERSON REGARDING THIS REPORT Daniel S. Gaafar

TELEPHONE (317) 237-5500 FAX #: (317) 237-5503

A. Summary of Real Estate Tax Cost

Enter the tax index number and real estate tax assessed for 2017 on the lines provided below. Enter only the portion of thecost that applies to the operation of the nursing home in Column D. Real estate tax applicable to any portion of the nursinghome property which is vacant, rented to other organizations, or used for purposes other than long term care must not beentered in Column D. Do not include cost for any period other than calendar year 2017.

(A) (B) (C) (D)Tax

Applicable toTax Index Number Property Description Total Tax Nursing Home

1. 18-36-403-013-0000 Nursing Facility $ 1,232,765.85 $ 1,232,765.85

2. $ $

3. $ $

4. $ $

5. $ $

6. $ $

7. $ $

8. $ $

9. $ $

10. $ $

TOTALS $ 1,232,765.85 $ 1,232,765.85

B. Real Estate Tax Cost Allocations

Does any portion of the tax bill apply to more than one nursing home, vacant property, or property which is not directlyused for nursing home services? YES X NO

If YES, attach an explanation and a schedule which shows the calculation of the cost allocated to the nursing home.(Generally the real estate tax cost must be allocated to the nursing home based upon sq. ft. of space used.)

C. Tax Bills

Attach a copy of the original 2017 tax bills which were listed in Section A to this statement. Be sure to use the 2017tax bill which is normally paid during 2018.

PLEASE NOTE: Payment information from the Internet or otherwise is not considered acceptable tax billdocumentation . Facilities located in Cook County are required to provide copies of their original second installment tax bill.

Page 10A

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 11Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18X. BUILDING AND GENERAL INFORMATION:

A. Square Feet: 112,340 B. General Construction Type: Exterior Brick Frame Concrete / Steel Number of Stories 5

C. Does the Operating Entity? (a) Own the Facility X (b) Rent from a Related Organization. (c) Rent from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI. Those checking (c) may complete Schedule XI or Schedule XII-A. See instructions.)

D. Does the Operating Entity? X (a) Own the Equipment X (b) Rent equipment from a Related Organization. (c) Rent equipment from Completely Unrelated Organization.

(Facilities checking (a) or (b) must complete Schedule XI-C. Those checking (c) may complete Schedule XI-C or Schedule XII-B. See instructions.)

E. List all other business entities owned by this operating entity or related to the operating entity that are located on or adjacent to this nursing home's grounds(such as, but not limited to, apartments, assisted living facilities, day training facilities, day care, independent living facilities, CNA training facilities, etc.)List entity name, type of business, square footage, and number of beds/units available (where applicable).

F. Does this cost report reflect any organization or pre-operating costs which are being amortized? YES X NOIf so, please complete the following:

1. Total Amount Incurred: 2. Number of Years Over Which it is Being Amortized:

3. Current Period Amortization: 4. Dates Incurred:

Nature of Costs:(Attach a complete schedule detailing the total amount of organization and pre-operating costs.)

XI. OWNERSHIP COSTS: 1 2 3 4

A. Land. Use Square Feet Year Acquired Cost1 Land $ 950,000 12 23 TOTALS $ 950,000 3

HFS 3745 (N-4-99) IL478-2471


XI. OWNERSHIP COSTS (continued) B. Building and Improvement Costs-Including Fixed Equipment. (See instructions.) Round all numbers to nearest dollar.

1 2 3 4 5 6 7 8 9 FOR BHF USE ONLY Year Year Current Book Life Straight Line Accumulated

Beds* Acquired Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation4 404 2009 $ 7,600,000 $ 194,872 39 $ 194,872 $ $ 1,964,947 45 56 67 78 8

Improvement Type**9 Combined 2005 Building Improvements 2005 323,803 21,587 15 21,587 288,930 9

10 2005 Assets not allowed for increased capital reimbursement 2005 6,291 419 15 419 5,612 1011 1112 Combined 2006 Building Improvements 2006 195,836 13,056 15 13,056 170,346 1213 2006 Assets not allowed for increased capital reimbursement 2006 15,508 1,034 15 1,034 13,490 1314 1415 Air Conditioner 2007 10,330 265 39 265 3,179 1516 Fire Sprinkler 2007 4,775 122 39 122 1,468 1617 Fire System 2007 1,290 33 39 33 397 1718 Auto Transfer Switch 2007 838 21 39 21 256 1819 Video SecurityCameras 2007 3,900 100 39 100 1,200 1920 Shower Room Tile 2007 9,010 231 39 231 2,772 2021 Shower Room Tile 2007 3,543 91 39 91 1,091 2122 Cubicle curtains 2007 4,059 104 39 104 1,249 2223 Shower Room Tile 2007 5,497 141 39 141 1,692 2324 Air Conditioner 2007 500 13 39 13 155 2425 Air Conditioner 2007 500 13 39 13 155 2526 Signage 2007 1,692 43 39 43 519 2627 Fire Sprinkler 2007 1,373 35 39 35 422 2728 Electrical work in reception area 2007 490 13 39 13 153 2829 Painting - Shower Room 2007 1,000 26 39 26 309 2930 Painting - Shower Room 2007 2,000 51 39 51 614 3031 Painting - Shower Room 2007 3,000 77 39 77 923 3132 Painting - Shower Room 2007 3,000 77 39 77 923 3233 Toner 2007 13 39 3 3334 Freezer maint 2007 3,188 82 39 82 982 3435 Doors 2007 1,595 41 39 41 491 3536 36

*Total beds on this schedule must agree with page 2. See Page 12A, Line 70 for total**Improvement type must be detailed in order for the cost report to be considered complete

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12AFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18


1 3 4 5 6 7 8 9Year Current Book Life Straight Line Accumulated

Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation37 Doors 2007 $ 1,595 $ 41 39 $ 41 $ $ 491 3738 Air Conditioner 2007 500 13 39 13 155 3839 Locks on Gate 2007 3,509 90 39 90 1,080 3940 Parking Lot Paving 2007 20,000 513 39 513 6,154 4041 Parking Lot Paving 2007 21,410 549 39 549 6,587 4142 Fencing 2007 1,550 40 39 40 478 4243 Fencing 2007 1,500 38 39 38 460 4344 Asbestos removal 2007 2,370 61 39 61 730 4445 4546 Pump 2008 1,498 38 39 38 421 4647 Sprinkler Systems 2008 12,457 319 39 319 3,512 4748 Sprinkler Systems 2008 1,625 42 39 42 460 4849 Smoke Detector 2008 1,342 34 39 34 377 4950 Refrigeration 2008 4,250 109 39 109 1,199 5051 Refrigeration 2008 5,291 136 39 136 1,494 5152 Refrigeration 2008 3,735 96 39 96 1,054 5253 Refrigeration 2008 6,950 178 39 178 1,959 5354 Refrigeration 2008 2,455 63 39 63 693 5455 Refrigeration 2008 971 25 39 25 274 5556 Refrigeration 2008 1,678 43 39 43 473 5657 Refrigeration 2008 2,865 73 39 73 806 5758 Tiling for Shower room 2008 276 7 39 7 78 5859 Elevator 2008 1,270 33 39 33 360 5960 Roof 2008 4,094 105 39 105 1,155 6061 Fire Doors 2008 2,670 68 39 68 751 6162 Fire Doors 2008 907 23 39 23 255 6263 Hot Water Heater 2008 8,875 228 39 228 2,505 6364 Elevator 2008 3,008 77 39 77 848 6465 Roof 2008 35,700 915 39 915 10,068 6566 Brick work on Bldg 2008 17,850 458 39 458 5,036 6667 Windows 2008 135,000 3,462 39 3,462 38,081 6768 2nd & 3rd floor tiling & nurses station 2008 80,000 2,051 39 2,051 22,563 6869 6970 TOTAL (lines 4 thru 69) $ 8,590,229 $ 242,475 $ 242,475 $ $ 2,572,835 70

**Improvement type must be detailed in order for the cost report to be considered complete.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12BFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12A, Carried Forward $ 8,590,229 $ 242,475 $ 242,475 $ $ 2,572,835 12 Renovation 2008 41,403 1,062 39 1,062 11,679 23 CATV wiring 2008 8,000 205 39 205 2,256 34 CATV wiring 2008 8,000 205 39 205 2,256 45 CATV wiring 2008 16,000 411 39 410 (1) 4,513 56 67 Alarm System 2009 629 16 39 16 161 78 Wiring 2009 6,300 162 39 162 1,616 89 Room Signs 2009 5,405 138 39 139 1 1,385 9

10 Brickwork 2009 39,000 1,000 39 1,000 9,998 1011 1112 Hardware, Paint, tiles, fixtures for entire construction project 2010 236,400 6,062 39 6,062 39,522 1213 Labor-replace tiles, drywall, covebase & floor tiles 2010 195,524 5,013 39 5,013 32,685 1314 2nd floor drywall, tiles, paint, baseboard & plumbing 2010 57,229 1,467 39 1,467 9,566 1415 Cubicle curtain tracks & new room signs 2010 15,357 394 39 394 2,568 1516 Sewer maintenance and upgrade 2010 3,379 87 39 87 566 1617 Re-key entire building 2010 12,388 318 39 318 2,072 1718 New fire doors 2010 30,801 790 39 790 5,150 1819 Patch & re-roof overhang 2010 3,450 88 39 88 575 1920 Cabling for nurse call system 2010 2,763 71 39 71 462 2021 Labor for painting and paint supplies for entire building 2010 259,159 6,645 39 6,645 43,324 2122 Outside concrete & brickwork 2010 48,642 1,247 39 1,247 8,131 2223 Bathroom sink lens 2010 2,741 70 39 70 457 2324 Insulation of boilers 2010 3,700 95 39 95 619 2425 Light fixtures, circuits, electric box upgrades 2010 32,441 832 39 832 5,424 2526 Painting & murals on Alzheimers unit 2010 15,245 391 39 391 2,549 2627 Drywall & ceiling tile work throughout facility 2010 202,079 5,182 39 5,182 33,783 2728 New front doors 2010 15,099 387 39 387 2,524 2829 New A/C units, exhaust fans & duct work 2010 54,199 1,390 39 1,390 9,062 2930 Wall plaster & change electrical outlets 2010 53,650 1,376 39 1,376 8,970 3031 Air conditioning panels 2010 5,657 145 39 145 945 3132 Post construction clean up 2010 15,889 407 39 407 2,655 3233 3334 TOTAL (lines 1 thru 33) $ 9,980,758 $ 278,131 $ 278,131 $ $ 2,818,308 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12CFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12B, Carried Forward $ 9,980,758 $ 278,131 $ 278,131 $ $ 2,818,308 12 Repair asphalt 2010 2,867 74 39 74 481 23 Replace, water supply lines & valves 2010 27,303 700 39 700 4,564 34 Drainage pipe 2010 3,056 78 39 78 510 45 Replace shower valves, water lines, repipe & rod out sewer 2010 21,183 543 39 543 3,541 56 Repair water heaters 2010 2,830 73 39 73 475 67 2010 Assets not allowed for increased capital reimbursement 2010 72,793 1,865 39 1,866 1 12,165 78 89 Fix Hand Rails and Water Pumps 2011 16,413 421 39 421 3,367 9

10 Put Up Signs, Repair Stairs, Install New Cabinets 2011 1,035 27 39 27 214 1011 Replace Waste Drain and Break 2011 2,950 76 39 76 607 1112 Install Fire Dampers 2011 6,500 167 39 167 1,335 1213 Update and Refit Lighting and Fixtures 2011 33,557 860 39 860 6,882 1314 Replace Stairs 2011 2,990 77 39 77 615 1415 Install and Updated Cabinets 2011 6,050 154 39 155 1 1,240 1516 2011 Assets not allowed for increased capital reimbursement 2011 15,706 403 39 403 3,220 1617 1718 Replaced IFC-320 and TM-4 controls 2012 9,460 243 39 243 1,703 1819 Relocate generator panels 2012 1,883 48 39 48 337 1920 install sprinkler head in elevator shafts 2012 5,973 153 39 153 1,072 2021 Fire Panel Call, contols, pull & trim outside west stand pipe 2012 5,439 140 39 139 (1) 975 2122 7.5T Dry AC 2012 2,734 70 39 70 490 2223 Advantage Carpet Ware 2012 3,290 84 39 84 589 2324 2425 Flooring / Tiles / Toilets in 5th floor resident rooms 2013 3,030 78 39 78 1,112 2526 Wall repair, preparation and cove base in 5th floor res. Rooms 2013 2,811 72 39 72 1,030 2627 Flooring - for 5th floor resident rooms 2013 5,494 141 39 141 2,014 2728 Replace roof Exhaust 2013 4,805 123 39 123 1,760 2829 Elevator 2013 28,000 718 39 718 10,262 2930 Repair Elevator 2013 3,850 99 39 99 1,412 3031 Wall repair - 5th floor 2013 3,000 77 39 77 1,100 3132 Condenser - Kitchen / Barber Shop 2013 1,325 34 39 34 486 3233 3334 TOTAL (lines 1 thru 33) $ 10,277,085 $ 285,729 $ 285,730 $ 1 $ 2,881,866 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12DFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12C, Carried Forward $ 10,277,085 $ 285,729 $ 285,730 $ 1 $ 2,881,866 12 Sprinklers 2013 2,825 72 39 72 1,034 23 Emergency Generator 2013 4,442 114 39 114 1,628 34 45 Remove wallpaper, paint wall, cove base 4th floor dining room 2014 2,469 63 39 63 904 56 Install door restrictors and door detectors on elevators 2014 3,520 90 39 90 1,289 67 Condenser in main boiler room and service roof top units 2014 25,362 650 39 650 9,294 78 Install new hydrant and valve in pump room 2014 11,604 298 39 298 4,255 89 Rod out kitchen waste line & main branch from nrsg station 2014 3,085 79 39 79 1,130 9

10 Replace 205 linear feet of fence on patio including gate 2014 16,000 410 39 410 5,863 1011 5 BTU wall units for MDS, Bookkeeping, Rms 206, 318, & 323 2014 7,335 188 39 188 2,688 1112 Golden teak flooring for hallway and dining room on 1st floor 2014 18,184 466 39 466 6,663 1213 2 rolls of wall covering for hallway and dining room on 1st flr 2014 2,139 55 39 55 784 1314 2700 sq ft of plank flooring for hallway and dining 1st floor 2014 2,993 77 39 77 1,098 1415 Painted seven patient rooms (201, 202, 404, 408, 416, 303, 322) 2014 3,435 88 39 88 1,259 1516 Install insulation on roof air handler panels and seal roof units 2014 1,975 51 39 51 725 1617 Tuck pointing and window caulking on entire exterior facility 2014 13,469 345 39 345 4,935 1718 3rd flr door lock on elevator 2, new infared door detector also 2014 1,650 42 39 42 603 1819 Paint walls in 536 - 544, 503, & 504; remove therapy closet 2014 29,709 762 39 762 10,889 1920 Non-Allowable Assets 2014 15,196 390 39 390 5,571 2021 2122 Hallway and dining renovation - Paint, flooring, hand rails, and ot 2015 112,702 2,890 39 2,890 11,560 2223 Flooring for new dining room on 4th floor 2015 3,175 81 39 81 324 2324 Furnish & Install New Flooring on 1st Floor 2015 2,993 77 39 77 308 2425 Remove old flooring, toilets, and countertops and install new blind 2015 6,391 164 39 164 656 2526 Remove wall for dining room and install light fixtures 2015 5,585 143 39 143 572 2627 Handrails, wall coverings, signage, and blinds 2015 35,470 909 39 909 3,636 2728 Elevator panel, elevator hand railing 2015 11,000 282 39 282 1,128 2829 Replace 4th floor electrical wiring 2015 7,900 203 39 203 812 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 10,627,692 $ 294,718 $ 294,719 $ 1 $ 2,961,474 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12EFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12D, Carried Forward $ 10,627,692 $ 294,718 $ 294,719 $ 1 $ 2,961,474 12 Replace U-bends on boiler 2015 2,800 72 39 72 288 23 Plumbing - Sink faucet handles 2015 6,965 179 39 179 716 34 Install flooring and corner guards on 1st floor 2015 3,660 94 39 94 376 45 Replace U-bends on boiler 2015 3,268 84 39 84 336 56 Remove flooring and install new floor on 5th floor 2015 2,857 73 39 73 292 67 Steel door 2015 4,423 113 39 113 452 78 Replace Tiles, Cove Base, Cabinets & Floor in Therapy Rm 2015 7,872 202 39 202 808 89 New lock systems 2015 21,204 544 39 544 2,176 9

10 Smoking shelter 2015 4,875 125 39 125 500 1011 Parking lot paving 2015 38,634 991 39 991 3,964 1112 New lock systems 2015 4,575 117 39 117 468 1213 Patient room doors 2015 2,900 74 39 74 296 1314 Granite tops for dining room 2015 3,400 87 39 87 348 1415 New door 2015 2,000 51 39 51 204 1516 Replace laundry outside doors 2015 1,400 36 39 36 144 1617 Replace laundry outside doors 2015 2,147 55 39 55 220 1718 Air conditioning unit 2015 2,975 76 39 76 304 1819 Pit ladders for elevator 2015 3,400 87 39 87 348 1920 2021 Light Pole Brackets 2016 3,600 92 39 92 276 2122 Replace Laundry MLB Panel 2016 4,700 121 39 121 363 2223 Flooring & Painting, double doors on 2nd and 3rd floors, 2016 17,480 448 39 448 1,344 2324 2nd floor stairwell door, 4th floor dining room walls and 2425 cove base 2526 Replace HVAC 2016 2,950 76 39 76 228 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 10,775,777 $ 298,515 $ 298,516 $ 1 $ 2,975,925 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12FFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12E, Carried Forward $ 10,775,777 $ 298,515 $ 298,516 $ 1 $ 2,975,925 12 Mural for 4th Floor Alzheimer Unit 2017 3,600 92 39 92 138 23 Air Conditioners 2017 2,950 76 39 76 114 34 New Roof for Upper Main Roof 2017 23,350 599 39 599 898 45 Air Conditioners 2017 2,950 76 39 76 114 56 New Condensor for AC Unit in Beauty Supply Room 2017 29,950 768 39 768 1,152 67 Replace Car Sills for Four Elevators 2017 3,120 80 39 80 120 78 New Air Conditioners 2017 2,950 76 39 76 114 89 New Heating Boilers for Mezzanine Area 2017 34,260 878 39 878 1,317 9

10 New Domestic Hot Water System 2017 48,520 1,244 39 1,244 1,866 1011 1112 Replace light fixtures & repair heater room 435 2018 4,055 52 39 52 52 1213 Main control circuit board for generator 2018 3,045 39 39 39 39 1314 Air Conditioners in patient rooms 2018 2,950 38 39 38 38 1415 Restoration of nurse call station on 3rd floor 2018 3,161 41 39 41 (1) 41 1516 Custom modify lourve windows in kitchen 2018 2,500 32 39 32 32 1617 new shelving for freezers 2018 4,183 54 39 54 (1) 54 1718 Paint 4th floor cooridor & dining room 2018 3,995 51 39 51 51 1819 Paint 3rd floor corridor & doors 2018 3,995 51 39 51 51 1920 New Air Conditioners in patient rooms 2018 3,020 39 39 39 (1) 39 2021 1st 4th 5th floor smoke compartments into compliance 2018 8,287 106 39 106 106 2122 Replace jockey pump for sprinkler system 2018 8,900 114 39 114 114 2223 Replace fire sprinkler heads in laundry chute 2018 2,820 36 39 36 36 2324 New Air Conditioners in patient rooms 2018 3,720 48 39 48 (1) 48 2425 New flooring for administrator office 2018 2,639 34 39 34 34 2526 New Air Conditioners in patient rooms 2018 3,020 39 39 39 (1) 39 2627 New motor for 1st floor exhaust fan 2018 3,999 51 39 52 1 51 2728 Cubicle curtains in patient rooms 2018 15,516 199 39 199 199 2829 New doors for linen chute & rubbish chute doors 2018 6,937 89 39 89 89 2930 New hopper door for linen chute 2018 3,788 49 39 49 (1) 49 3031 New LVT flooring for admin office and conference room 2018 4,527 58 39 58 58 3132 New Air Conditioners in patient rooms 2018 3,020 39 39 39 (1) 39 3233 3334 TOTAL (lines 1 thru 33) $ 11,025,504 $ 303,663 $ 303,661 $ (2) $ 2,983,017 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 12GFacility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18



Improvement Type** Constructed Cost Depreciation in Years Depreciation Adjustments Depreciation1 Totals from Page 12F, Carried Forward $ 11,025,504 $ 303,663 $ 303,661 $ (2) $ 2,983,017 12 New computer wiring for building 2018 8,880 114 39 114 114 23 New emergency shutoff valve for boilers on 5th floor 2018 2,610 33 39 34 1 33 34 Patch for field or wall flashings for the roof 2018 6,900 88 39 89 1 88 45 Labor to install new lvt flooring in admin office and conference room 2018 1,777 23 39 23 23 56 New LVT flooring in admin office and conference room 2018 1,378 18 39 18 (1) 18 67 78 89 9

10 1011 1112 1213 1314 1415 1516 1617 1718 1819 1920 2021 2122 2223 2324 2425 2526 2627 2728 2829 2930 3031 3132 3233 3334 TOTAL (lines 1 thru 33) $ 11,047,049 $ 303,939 $ 303,938 $ (2) $ 2,983,293 34


HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 13Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18XI. OWNERSHIP COSTS (continued)

C. Equipment Costs-Excluding Transportation. (See instructions.) Category of 1 Current Book Straight Line 4 Component Accumulated Equipment Cost Depreciation 2 Depreciation 3 Adjustments Life 5 Depreciation 6

71 Purchased in Prior Years $ $ $ $ 5 $ 7172 Current Year Purchases 48,602 48,602 9,720 (38,882) 5 48,602 7273 Fully Depreciated Assets 4,629,102 5 4,629,102 7374 7475 TOTALS $ 4,677,704 $ 48,602 $ 9,720 $ (38,882) $ 4,677,704 75

D. Vehicle Costs. (See instructions.)*1 Model, Make Year 4 Current Book Straight Line 7 Life in Accumulated

Use and Year 2 Acquired 3 Cost Depreciation 5 Depreciation 6 Adjustments Years 8 Depreciation 976 $ $ $ $ $ 7677 7778 7879 7980 TOTALS $ $ $ $ $ 80

E. Summary of Care-Related Assets 1 2Reference Amount

81 Total Historical Cost (line 3, col.4 + line 70, col.4 + line 75, col.1 + line 80, col.4) + (Pages 12B thru 12I, if applicable) $ 16,674,753 8182 Current Book Depreciation (line 70, col.5 + line 75, col.2 + line 80, col.5) + (Pages 12B thru 12I, if applicable) $ 352,541 8283 Straight Line Depreciation (line 70, col.7 + line 75, col.3 + line 80, col.6) + (Pages 12B thru 12I, if applicable) $ 313,658 83 **84 Adjustments (line 70, col.8 + line 75, col.4 + line 80, col.7) + (Pages 12B thru 12I, if applicable) $ (38,883) 8485 Accumulated Depreciation (line 70, col.9 + line 75, col.6 + line 80, col.9) + (Pages 12B thru 12I, if applicable) $ 7,660,997 85

F. Depreciable Non-Care Assets Included in General Ledger. (See instructions.) G. Construction-in-Progress1 2 Current Book Accumulated

Description & Year Acquired Cost Depreciation 3 Depreciation 4 Description Cost86 $ $ $ 86 92 $ 9287 87 93 9388 88 94 9489 89 95 $ 9590 9091 TOTALS $ $ $ 91 * Vehicles used to transport residents to & from

day training must be recorded in XI-F, not XI-D.

** This must agree with Schedule V line 30, column 8.

HFS 3745 (N-4-99) IL478-2471


XII. RENTAL COSTSA. Building and Fixed Equipment (See instructions.) 1. Name of Party Holding Lease: N/A 2. Does the facility also pay real estate taxes in addition to rental amount shown below on line 7, column 4? If NO, see instructions. YES NO 00

001 2 3 4 5 6

Year Number Original Rental Total Years Total YearsConstructed of Beds Lease Date Amount of Lease Renewal Option*

Original 10. Effective dates of current rental agreement:3 Building: $ 3 Beginning4 Additions 4 Ending5 56 6 11. Rent to be paid in future years under the current7 TOTAL $ 7 rental agreement:

** 8. List separately any amortization of lease expense included on page 4, line 34. Fiscal Year Ending Annual Rent This amount was calculated by dividing the total amount to be amortized by the length of the lease . 12. /2019 $

13. /2020 $ 9. Option to Buy: YES NO Terms: * 14. /2021 $

B. Equipment-Excluding Transportation and Fixed Equipment. (See instructions.) 15. Is Movable equipment rental included in building rental? YES NO 16. Rental Amount for movable equipment: $ Description:

(Attach a schedule detailing the breakdown of movable equipment)C. Vehicle Rental (See instructions.)

1 2 3 4Model Year Monthly Lease Rental Expense

Use and Make Payment for this Period * If there is an option to buy the building,17 $ $ 17 please provide complete details on attached18 18 schedule.19 1920 20 ** This amount plus any amortization of lease21 TOTAL $ $ 21 expense must agree with page 4, line 34.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 15Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18XIII. EXPENSES RELATING TO CERTIFIED NURSE AIDE (CNA) TRAINING PROGRAMS (See instructions.)

A. TYPE OF TRAINING PROGRAM (If CNAs are trained in another facility program, attach a schedule listing the facility name, address and cost per CNA trained in that facility.)

1. HAVE YOU TRAINED CNAs YES 2. CLASSROOM PORTION: 3. CLINICAL PORTION: DURING THIS REPORT PERIOD? X NO IN-HOUSE PROGRAM IN-HOUSE PROGRAM

IN OTHER FACILITY IN OTHER FACILITY If "yes", please complete the remainder of this schedule. If "no", provide an COMMUNITY COLLEGE HOURS PER CNA explanation as to why this training was not necessary. HOURS PER CNA

B. EXPENSES C. CONTRACTUAL INCOMEALLOCATION OF COSTS (d)

In the box below record the amount of income your1 2 3 4 facility received training CNAs from other facilities.

FacilityDrop-outs Completed Contract Total $

1 Community College Tuition $ $ $ $2 Books and Supplies D. NUMBER OF CNAs TRAINED3 Classroom Wages (a)4 Clinical Wages (b) COMPLETED5 In-House Trainer Wages (c) 1. From this facility6 Transportation 2. From other facilities (f)7 Contractual Payments DROP-OUTS8 CNA Competency Tests 1. From this facility9 TOTALS $ $ $ $ 2. From other facilities (f)10 SUM OF line 9, col. 1 and 2 (e) $ TOTAL TRAINED

(a) Include wages paid during the classroom portion of training. Do not include fringe benefits. (e) The total amount of Drop-out and Completed Costs for(b) Include wages paid during the clinical portion of training. Do not include fringe benefits. your own CNAs must agree with Sch. V, line 13, col. 8.(c) For in-house training programs only. Do not include fringe benefits. (f) Attach a schedule of the facility names and addresses(d) Allocate based on if the CNA is from your facility or is being contracted to be trained in of those facilities for which you trained CNAs. your facility. Drop-out costs can only be for costs incurred by your own CNAs.

HFS 3745 (N-4-99) IL478-2471


XIV. SPECIAL SERVICES (Direct Cost) (See instructions.)1 2 3 4 5 6 7 8

Schedule V Staff Outside Practitioner SuppliesService Line & Column Units of Cost (other than consultant) (Actual or) Total Units Total Cost

Reference Service Units Cost Allocated) (Column 2 + 4) (Col. 3 + 5 + 6)1 Licensed Occupational Therapist 10a-3 hrs $ 8,396 $ 535,916 $ 8,396 $ 535,916 1

Licensed Speech and Language2 Development Therapist 10a-3 hrs 1,359 25,612 1,359 25,612 23 Licensed Recreational Therapist hrs 34 Licensed Physical Therapist 10a-3 hrs 9,387 472,799 9,387 472,799 45 Physician Care visits 56 Dental Care visits 67 Work Related Program hrs 78 Habilitation hrs 8

# of9 Pharmacy 39-2 prescrpts 146,298 146,298 9

Psychological Services (Evaluation and Diagnosis/

10 Behavior Modification) hrs 1011 Academic Education hrs 1112 Other (specify): X-Ray & Lab 39-2 5,555 5,555 12

13 Other (specify): 13

14 TOTAL $ 19,142 $ 1,034,327 $ 151,853 19,142 $ 1,186,180 14

NOTE: This schedule should include fees (other than consultant fees) paid to licensed practitioners. Consultant fees should be detailed on Schedule XVIII-B. Salaries of unlicensed practitioners, such as CNAs, who help with the above activities should not be listed on this schedule.

HFS 3745 (N-4-99) IL478-2471


XV. BALANCE SHEET - Unrestricted Operating Fund. As of 12/31/18 (last day of reporting year) This report must be completed even if financial statements are attached.

1 2 After 1 2 After Operating Consolidation* Operating Consolidation*

A. Current Assets C. Current Liabilities1 Cash on Hand and in Banks $ (94,519) $ 119,980 1 26 Accounts Payable $ 12,573,864 $ 12,879,922 262 Cash-Patient Deposits 2 27 Officer's Accounts Payable 27

Accounts & Short-Term Notes Receivable- 28 Accounts Payable-Patient Deposits (63,031) (63,031) 283 Patients (less allowance ) 2,117,526 2,117,526 3 29 Short-Term Notes Payable 420,884 294 Supply Inventory (priced at ) 4 30 Accrued Salaries Payable 483,808 483,808 305 Short-Term Investments 5 Accrued Taxes Payable6 Prepaid Insurance 528,952 528,952 6 31 (excluding real estate taxes) 109,257 109,257 317 Other Prepaid Expenses 230,835 230,835 7 32 Accrued Real Estate Taxes(Sch.IX-B) 328 Accounts Receivable (owners or related parties) 8 33 Accrued Interest Payable 63,004 339 Other(specify): Escrow Accounts 2,521,213 2,746,207 9 34 Deferred Compensation 34

TOTAL Current Assets 35 Federal and State Income Taxes 3510 (sum of lines 1 thru 9) $ 5,304,007 $ 5,743,500 10 Other Current Liabilities(specify):

B. Long-Term Assets 36 Settlement Reserves / LOC (21,446,679) (21,446,679) 3611 Long-Term Notes Receivable 11 37 RP Loan / Working Capital (3,236,971) (2,550,171) 3712 Long-Term Investments 12 TOTAL Current Liabilities13 Land 950,000 13 38 (sum of lines 26 thru 37) $ (11,579,752) $ (10,103,006) 3814 Buildings, at Historical Cost 7,600,000 14 D. Long-Term Liabilities15 Leasehold Improvements, at Historical Cost 3,447,047 3,447,047 15 39 Long-Term Notes Payable 21,815,787 3916 Equipment, at Historical Cost 1,088,715 4,677,705 16 40 Mortgage Payable 4017 Accumulated Depreciation (book methods) (2,107,059) (7,660,996) 17 41 Bonds Payable 4118 Deferred Charges 18 42 Deferred Compensation 4219 Organization & Pre-Operating Costs 103,820 7,196,852 19 Other Long-Term Liabilities(specify):

Accumulated Amortization - 43 4320 Organization & Pre-Operating Costs (43,170) (6,826,589) 20 44 4421 Restricted Funds 21 TOTAL Long-Term Liabilities22 Other Long-Term Assets (speReplacement reserves 626,200 626,200 22 45 (sum of lines 39 thru 44) $ $ 21,815,787 4523 Other(specify): LT Escrows 1,107,112 23 TOTAL LIABILITIES

TOTAL Long-Term Assets 46 (sum of lines 38 and 45) $ (11,579,752) $ 11,712,781 4624 (sum of lines 11 thru 23) $ 3,115,553 $ 11,117,331 24

47 TOTAL EQUITY(page 18, line 24) $ 19,999,312 $ 5,148,050 47TOTAL ASSETS TOTAL LIABILITIES AND EQUITY

25 (sum of lines 10 and 24) $ 8,419,560 $ 16,860,831 25 48 (sum of lines 46 and 47) $ 8,419,560 $ 16,860,831 48

*(See instructions.)

HFS 3745 (N-4-99) IL478-2471


XVI. STATEMENT OF CHANGES IN EQUITY1

Total1 Balance at Beginning of Year, as Previously Reported $ 14,996,368 12 Restatements (describe): 23 34 45 56 Balance at Beginning of Year, as Restated (sum of lines 1-5) $ 14,996,368 6

A. Additions (deductions):7 NET Income (Loss) (from page 19, line 43) 8,003,404 78 Aquisitions of Pooled Companies 89 Proceeds from Sale of Stock 9

10 Stock Options Exercised 1011 Contributions and Grants 1112 Expenditures for Specific Purposes 1213 Dividends Paid or Other Distributions to Owners (3,000,462) 1314 Donated Property, Plant, and Equipment 1415 Other (describe) Rounding 2 1516 Other (describe) 1617 TOTAL Additions (deductions) (sum of lines 7-16) $ 5,002,944 17

B. Transfers (Itemize):18 1819 1920 2021 2122 2223 TOTAL Transfers (sum of lines 18-22) $ 2324 BALANCE AT END OF YEAR (sum of lines 6 + 17 + 23) $ 19,999,312 24 *

* This must agree with page 17, line 47.

HFS 3745 (N-4-99) IL478-2471


XVII. INCOME STATEMENT (attach any explanatory footnotes necessary to reconcile this schedule to Schedules V and VI.) All required classifications of revenue and expense must be provided on this form, even if financial statements are attached. Note: This schedule should show gross revenue and expenses. Do not net revenue against expense

1 2I. Revenue Amount II. Expenses Amount

A. Inpatient Care A. Operating Expenses1 Gross Revenue -- All Levels of Care $ 21,474,780 1 31 General Services 3,114,149 312 Discounts and Allowances for all Levels 1,162,239 2 32 Health Care 7,482,916 323 SUBTOTAL Inpatient Care (line 1 minus line 2) $ 22,637,019 3 33 General Administration 3,729,142 33

B. Ancillary Revenue B. Capital Expense4 Day Care 4 34 Ownership (262,169) 345 Other Care for Outpatients 5 C. Ancillary Expense6 Therapy 645,586 6 35 Special Cost Centers 151,853 357 Oxygen 7 36 Provider Participation Fee 987,493 368 SUBTOTAL Ancillary Revenue (lines 4 thru 7) $ 645,586 8 D. Other Expenses (specify):

C. Other Operating Revenue 37 Bad Debt Expense 325,396 379 Payments for Education 9 38 38

10 Other Government Grants 10 39 3911 CNA Training Reimbursements 1112 Gift and Coffee Shop 12 40 TOTAL EXPENSES (sum of lines 31 thru 39)* $ 15,528,780 4013 Barber and Beauty Care 1314 Non-Patient Meals 14 41 Income before Income Taxes (line 30 minus line 40)** 8,003,404 4115 Telephone, Television and Radio 1516 Rental of Facility Space 16 42 Income Taxes 4217 Sale of Drugs 69,952 1718 Sale of Supplies to Non-Patients 18 43 NET INCOME OR LOSS FOR THE YEAR (line 41 minus line 42) $ 8,003,404 4319 Laboratory 3,152 1920 Radiology and X-Ray 2,670 20 III. Net Inpatient Revenue detailed by Payer Source21 Other Medical Services 21 44 Medicaid - Net Inpatient Revenue $ 20,133,035 4422 Laundry 22 45 Private Pay - Net Inpatient Revenue 67,155 4523 SUBTOTAL Other Operating Revenue (lines 9 thru 22) $ 75,774 23 46 Medicare - Net Inpatient Revenue 1,743,067 46

D. Non-Operating Revenue 47 Other-(specify) 693,762 4724 Contributions 24 48 Other-(specify) 4825 Interest and Other Investment Income*** 143,736 25 49 TOTAL Inpatient Care Revenue (This total must agree to Line 3) $ 22,637,019 4926 SUBTOTAL Non-Operating Revenue (lines 24 and 25) $ 143,736 26

E. Other Revenue (specify):**** * This must agree with page 4, line 45, column 4.27 Settlement Income (Insurance, Legal, Etc.) 27 ** Does this agree with taxable income (loss) per Federal Income28 28 Tax Return? Yes If not, please attach a reconciliation.

28a Miscellaneous Revenue 30,069 28a *** See the instructions. If this total amount has not been offset against interest29 SUBTOTAL Other Revenue (lines 27, 28 and 28a) $ 30,069 29 expense on Schedule V, line 32, please include a detailed explanation.

30 TOTAL REVENUE (sum of lines 3, 8, 23, 26 and 29) $ 23,532,184 30 ****Provide a detailed breakdown of "Other Revenue" on an attached sheet.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 20Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18XVIII. A. STAFFING AND SALARY COSTS (Please report each line separately.) (This schedule must cover the entire reporting period.) B. CONSULTANT SERVICES

1 2** 3 4 1 2 3# of Hrs. # of Hrs. Reporting Period Average Number Total Consultant Schedule VActually Paid and Total Salaries, Hourly of Hrs. Cost for Line &Worked Accrued Wages Wage Paid & Reporting Column

1 Director of Nursing 2,317 2,482 $ 138,644 $ 55.86 1 Accrued Period Reference2 Assistant Director of Nursing 11,079 12,156 448,462 36.89 2 35 Dietary Consultant 556 $ 19,476 1-3 353 Registered Nurses 11,235 12,113 405,609 33.49 3 36 Medical Director 364 Licensed Practical Nurses 58,917 64,316 2,241,652 34.85 4 37 Medical Records Consultant 375 CNAs & Orderlies 80,154 88,953 1,522,378 17.11 5 38 Nurse Consultant 1,348 47,169 10-3 386 CNA Trainees 6 39 Pharmacist Consultant 767 38,331 15-3 397 Licensed Therapist 7 40 Physical Therapy Consultant 408 Rehab/Therapy Aides 8 41 Occupational Therapy Consultant 419 Activity Director 21,409 23,589 462,690 19.61 9 42 Respiratory Therapy Consultant (851) (42,572) 10a-3 42

10 Activity Assistants 10 43 Speech Therapy Consultant 4311 Social Service Workers 25,871 27,372 493,398 18.03 11 44 Activity Consultant 4412 Dietician 12 45 Social Service Consultant 100 3,510 12-3 4513 Food Service Supervisor 13 46 Other(specify) 4614 Head Cook 14 47 4715 Cook Helpers/Assistants 42,189 46,430 665,005 14.32 15 48 4816 Dishwashers 1617 Maintenance Workers 15,424 16,793 277,861 16.55 17 49 TOTAL (lines 35 - 48) 1,920 $ 65,914 4918 Housekeepers 24,733 26,654 347,092 13.02 1819 Laundry 4,393 4,691 72,893 15.54 1920 Administrator 4,249 4,424 234,248 52.95 2021 Assistant Administrator 21 C. CONTRACT NURSES22 Other Administrative 22 1 2 323 Office Manager 23 Number Schedule V24 Clerical 11,679 13,104 199,450 15.22 24 of Hrs. Total Line &25 Vocational Instruction 25 Paid & Contract Column26 Academic Instruction 26 Accrued Wages Reference27 Medical Director 27 50 Registered Nurses $ 5028 Qualified MR Prof. (QMRP) 28 51 Licensed Practical Nurses 5129 Resident Services Coordinator 29 52 Certified Nurse Assistants/Aides 5230 Habilitation Aides (DD Homes) 3031 Medical Records 2,852 3,077 56,022 18.21 31 53 TOTAL (lines 50 - 52) $ 5332 Other Health Care(specify) 3233 Other(specify) Admissions Coord 3,853 4,239 96,461 22.76 3334 TOTAL (lines 1 - 33) 320,354 350,393 $ 7,661,865 * $ 21.87 34

* This total must agree with page 4, column 1, line 45. ** See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 21Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18XIX. SUPPORT SCHEDULES A. Administrative Salaries Ownership D. Employee Benefits and Payroll Taxes F. Dues, Fees, Subscriptions and Promotions

Name Function % Amount Description Amount Description AmountAngie Ramirez Administrator $ 50,457 Workers' Compensation Insurance $ 333,623 IDPH License Fee $Michael Brown Administrator 161,370 Unemployment Compensation Insurance 17,507 Advertising: Employee RecruitmentHamed Ishola Administrator 22,421 FICA Taxes 598,380 Health Care Worker Background Check

Employee Health Insurance 429,772 (Indicate # of checks performed ) Employee Meals Patient Background Checks Illinois Municipal Retirement Fund (IMRF)* IHCA 3,587Uniform Expense 7,624 IDPH 1,990

TOTAL (agree to Schedule V, line 17, col. 1) Employee Background Checks 1,565 Village of Bridgeview 988(List each licensed administrator separately.) $ 234,248 Pension 32,234 CMS 569B. Administrative - Other Employee Expense 13,758 Various 2,178

Less: Public Relations Expense ( ) Description Amount Non-allowable advertising ( )

$ Yellow page advertising ( )

TOTAL (agree to Schedule V, $ 1,434,463 TOTAL (agree to Sch. V, $ 9,312 line 22, col.8) line 20, col. 8)

TOTAL (agree to Schedule V, line 17, col. 3) $ E. Schedule of Non-Cash Compensation Paid G. Schedule of Travel and Seminar**(Attach a copy of any management service agreement) to Owners or EmployeesC. Professional Services Description Amount Vendor/Payee Type Amount Description Line # AmountBradley Associates Accounting $ 12,220 $ Out-of-State Travel $US Department of Education Legal 34,544Abbey Road Tax Consultants Legal 16,383Various Legal 217 In-State TravelInfinity Funding/Sedgwick Legal 169,770 Mileage 20,412MTS Consulting Professional (5,615) Auto Allowance 5,960Abbey Road Tax Consultants Professional 16,383Various Professional 5,836 Seminar ExpenseInfinity Healthcare Mgmt Professional/Mgmt 774,440 Education & Seminars 654Empire Risk Management Mgmt 12,925

Entertainment Expense ( )TOTAL (agree to Schedule V, line 19, column 3) TOTAL $ (agree to Sch. V,(For legal fee disclosure, see page 39 of instructions) $ 1,037,103 TOTAL line 24, col. 8) $ 27,026

* Attach copy of IMRF notifications **See instructions.

HFS 3745 (N-4-99) IL478-2471

STATE OF ILLINOIS Page 22Facility Name & ID Number Midway Neurological & Rehabilitation Center # 0047175 Report Period Beginning: 1/1/18 Ending: 12/31/18XX. GENERAL INFORMATION:

(1) Are nursing employees (RN,LPN,NA) represented by a union? Yes (13) Have costs for all supplies and services which are of the type that can be billed tothe Department, in addition to the daily rate, been properly classified

(2) Are there any dues to nursing home associations included on the cost report? Yes in the Ancillary Section of Schedule V? YesIf YES, give association name and amount. IHCA - $3,587

(14) Is a portion of the building used for any function other than long term care services for(3) Did the nursing home make political contributions or payments to a political the patient census listed on page 2, Section B? No For example,

action organization? Yes If YES, have these costs is a portion of the building used for rental, a pharmacy, day care, etc.) If YES, attachbeen properly adjusted out of the cost report? Yes a schedule which explains how all related costs were allocated to these functions.

(4) Does the bed capacity of the building differ from the number of beds licensed at the (15) Indicate the cost of employee meals that has been reclassified to employee benefitsend of the fiscal year? No If YES, what is the capacity? N/A on Schedule V. $ 0 Has any meal income been offset against

related costs? N/A Indicate the amount. $ N/A(5) Have you properly capitalized all major repairs and equipment purchases? Yes

What was the average life used for new equipment added during this period? 5 Years (16) Travel and Transportationa. Are there costs included for out-of-state travel? No

(6) Indicate the total amount of both disposable and non-disposable diaper expense If YES, attach a complete explanation.and the location of this expense on Sch. V. $ 78,830 Line 10-2 b. Do you have a separate contract with the Department to provide medical transportation for

residents? No If YES, please indicate the amount of income earned from such a(7) Have all costs reported on this form been determined using accounting procedures program during this reporting period. $ N/A

consistent with prior reports? Yes If NO, attach a complete explanation. c. What percent of all travel expense relates to transportation of nurses and patients? 0d. Have vehicle usage logs been maintained? N/A

(8) Are you presently operating under a sale and leaseback arrangement? No e. Are all vehicles stored at the nursing home during the night and all otherIf YES, give effective date of lease. N/A times when not in use? N/A

f. Has the cost for commuting or other personal use of autos been adjusted(9) Are you presently operating under a sublease agreement? YES X NO out of the cost report? N/A

g. Does the facility transport residents to and from day training? No(10) Was this home previously operated by a related party (as is defined in the instructions for Indicate the amount of income earned from providing such

Schedule VII)? YES NO X If YES, please indicate name of the facility, transportation during this reporting period. $ N/AIDPH license number of this related party and the date the present owners took over.

(17) Has an audit been performed by an independent certified public accounting firm? NoFirm Name: N/A

(11) Indicate the amount of the Provider Participation Fees paid and accrued to the Departmentduring this cost report period. $ 987,493 (18) Have all costs which do not relate to the provision of long term care been adjusted outThis amount is to be recorded on line 42 of Schedule V. out of Schedule V? Yes

(12) Are there any salary costs which have been allocated to more than one line on Schedule V (19) Has a schedule for the legal fees reported on the cost report been provided by the facility?for an individual employee? No If YES, attach an explanation of the allocation. See page 39 of the instructions for details. Yes

Attach invoices and a summary of services for all architect and appraisal fees

HFS 3745 (N-4-99) IL478-2471

Documents

midway neurological rehab ctr 2018 0047175 · 2019. 8. 22. · 3 PAC Expenses (243) 20 3 4 RP Profit (96) 10 4 5 RP Profit (820) 15 5 6 RP Profit (3,131) 39 6 7 Miscellaneous Income